Life • Annuities • IRAs
Subject:
From:
E-Mail:
Comments:
Full Name:
Proposed Insured:
	Age: | Sex: Male Female | Ht. Wt.
	Smoker? Yes No |  Any Tobacco? Yes No
Spouse:
	Age: | Sex: Male Female | Ht. Wt.
	Smoker? Yes No |  Any Tobacco? Yes No
Children:
	Age: | Sex: Male Female | Ht. Wt.
	Smoker? Yes No |  Any Tobacco? Yes No
Children:
	Age: | Sex: Male Female | Ht. Wt.
	Smoker? Yes No |  Any Tobacco? Yes No
Children:
	Age: | Sex: Male Female | Ht. Wt.
	Smoker? Yes No |  Any Tobacco? Yes No
Daytime Phone:
Evening Phone:
Best Time To Call:
Address:
City/State/Zip:
Occupation:	Self Employed? | Checking Account?
Current Life Insurance:	$ Amount: Type Coverage: Current Carrier:
Current Life Insurance:	$ Amount: Type Coverage: Current Carrier:
Health History:	Ever diagnosed, treated, or medicated for any condition for the:
	Heart   Respiratory System   High Blood Pressure High Cholesterol   Cancer   Other
Underwriting Factors:

Life • Annuities • IRAs
Subject:
From:
E-Mail:
Comments:
Full Name:
Name:	DOB
Spouse:	DOB
State Required Personal Injury Protection: | Deductible:
Coverage on Your Vehicle:
	Comprehensive Deductible: Collision Deductible: Tow/Labor: Rental:
Liability Limits:
	Bodily Injury: Property Damage : Unisured Motorist BI: Medical Payments :
State Required Personal Injury Protection: | Deductible:
Coverage On Your Vehicle:
	Comprehensive Deductible: Collision Deductible: Tow/Labor: Rental:
Liability Limits:
	Bodily Injury: Property Damage : Unisured Motorist BI: Medical Payments :
Name of Current Carrier:
Months of Previous Coverage:
# Days Lapse in Coverage:	| New Policy Term: 12 Months 6 Months
Accidents/Violations:	Operator# | Date
Description:
Accidents/Violations:	Operator# | Date
Description:

Fire • Dwelling • Mobile Home • Flood
Subject:
From:
E-Mail:
Comments:
Full Name:
Proposed Insured:	|  DOB | Sex: Male Female
Spouse:	|  DOB | Sex: Male Female
Daytime Phone:
Evening Phone:
Fax:
E-Mail:
Occupation:
Employer:
Years at Previous Employer:
Work Phone:
Spouse Occupation:
Spouse Employer:
Years at Previous Employer:
Spouse Work Phone:
Property Address:
City/State/Zip:
Prior Address:	# of Years:
Subdivision Name:
Gated Community:	Yes No
Patrol Security:	Yes No
Appraised Value:	$
Assoc. Assessment Amount:	$
Flood Zone	Yes No
This additonal information is required to obtain a mobile home, homeowners or fire dwelling quote.
Year:
Make:
Model:	Length: Width:
Serial Number:
Location:	Adult Family Subdivision Private Property
Lot#:
Occupancy:	Owner Tenant Unoccupied Vacant Occupied 10+ Months/Per Year
Appraised Value of Mobile Home:	| Total Purchase Price:
Use:	Primary Home Secondary Home Seasonal Rental Other Retired
Lot Size:
Inside City Limits:	Yes No
Streets Paved	Yes No
Number of Entrances:
Other Info:	Two Permanent Neighbors Live within 200 Feet 5 In 1/4 Mile If No, How Many 3 or More Lots Visible within 300 Feet 10 Units within 1500 Feet
Chassis Contruction:	(Wood, Steel, Vinyl, Aluminum or Other)
Foundation Construction:	(Continuous Masonry, Post and Pier with Skirting, or Other)
State Approved Tie-Downs:	Yes No
Permanent Connection to Utilities:	Electric Water Sewer Phone
Wiring:	Copper Aluminum | Last Inspected
Other:	Pool Dive Board Slide Locking Fence Trampoline Flood Zone 1/4 Mile Tidal Waters
Protection Device Type:	Fire Central Reporting Local Smoke Burglar System Central Reporting Fire Extinguisher Handrailings on Steps State Approved Tie-Downs
Any Animals:	Yes No  Breed:  Mixed Breed:
Any Property Claims in Past 5 Years:	Yes No | If yes, Explain
Any Bankruptcy or Judgements in Past 5 Years:	Yes No
Miles to Fire Dept.:
Miles to City:
Extended Theft:	Yes No
Photos of all homes are required prior to policy issue.

Submitting a quote request for an insurance quote does not obligate you to buy any product nor does it constitute an offer to sell on the part of Alto Insurance Corporation of Jacksonville. Submission of a quote request of application for insurance or through Alto Insurance Corporation of Jacksonville does not bind any insurance and in no way constitutes a contract or guarantees any coverage. The rate quoted in any proposal for insurance you may receive will be based on the information you provide. Alto Insurance is not responsible for the accuracy of that information of the resulting or the resulting quote. Alto Insurance is not responsible for any changes in an insurer's underwriting criteria or rates.

"The Right Choice for All Your Insurance Needs"
Alto Insurance Corporation
9825 San Jose Boulevard, Suite 36 (Mandarin Outback Plaza)
Jacksonville, FL  32257 • (904) 886-4222 • Fax:  (904) 886-4228
E-Mail:  CMontalto@aol.com

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